Accident Investigation Report

Accident Investigation Report

REF: Number Notification of Accident at work

In the event of an Accident, please complete the following:

Site: Date of Accident:

Department:

About the person involved in the accident:

Name:

Male: Female:

Address:

Date of birth: Home Telephone Number:

Occupation: Length of Service:

Operation: Site Name: Address: Shift Pattern: Time of Accident: (Please use 24 hr format)

Location of accident: (if off site please include address)

Warehouse Yard

Delivery Point Office

Pick up point Other (Please Specify)

Job Description at time of accident:

FLT driving Store

delivery/Collection

Unloading Garment processing

Loading Pack/repack

Order Picking

Other (Please Specify)

Environmental Conditions: Dark Light Poorly Lit Direct Sunlight Dry Wet Slippery Windy Hot Warm Humid Cold Even Floor Uneven Different levels Foggy Noisy Quiet Other:

Accident Investigation Report

Accident Causation:

Lifting

Pushing Removal of safety guards

Operation of equipment without authorisation/training

Not wearing PPE Cutting corners

Faulty equipment Pulling Impact injury

Slips Falls from height

Trips Falling stock/equipment

Falls Equipment failure

Personal Attack Horseplay

Other (Please specify)

Parts of the body Affected: First Aid

Abdomen Was first aid administered Yes No

Ankle Left Right Name of first aider:

Arm Left Right Were first aid facilities adequate

If not give reason why Back

Chest

Elbow Left Right

Eye Left Right

Foot Left Right Did you know the location of the first aider

Face Yes No

Finger(s) Left H Right H Did you know the location of the first aid box

Groin Yes No

Hand Left Right Was hospital treatment necessary

Head Yes No

Knee Left Right Accident Book

Leg Left Right Did you know the location of the accident book

Neck Yes No

Shoulder Has all the information required been entered into _{the accident book}

Thumb Left H Right H Yes No

Thigh Left Right Has it been signed and dated

Wrist Left Right Yes No

Was the injured person able to return to work after treatment Did the injured person go home

Did the injured person go to the hospital: if yes please include address of hospital

Accident Investigation Report

Personal Protective Equipment (PPE)

Is the wearing of any PPE mandatory for the task Yes No

Was PPE available for the injured person Yes No

What PPE equipment was the injured person wearing at the time of the accident

Steel toecap boots Yes No

High visibility jacket Yes No

Gloves Yes No

Eye protection Yes No

Hard hat Yes No

Fall and arrest harness Yes No

Ear protection Yes No

Accident Investigation Report

Injured Persons Statement:

Give as much accurate information as possible:

I hereby declare that the information recorded in this report is a true and accurate record of the accident/incident.

Accident Investigation Report

Witness Statement:

Please ensure that facts (not opinions) are recorded below.

Witnesses must have been there and seen and heard the occurrence for their statement to be of value.

Give as much accurate information as possible

Witness Name Home Address

Post Code Telephone Number Job Title Company Name

Address

I hereby declare that the information recorded in this report is a true and accurate record of the accident/incident.

Accident Investigation Report

About the person conducting this investigation:

Investigators Name Home Address Post Code Telephone Number Job title Company Name Works Address Post Code Department Job Title

Works Telephone contact Number

Were photographs taken at the seen of the accident Yes No

Was the injured person authorised to carry out the task being undertaken

Were any equipment / device(s) being used at the time of the accident If yes, was the equipment / device(s) maintained on a regular basis In your opinion, was the equipment / device(s) the cause or a contributory factor of the accident

If yes, was a pre-shift inspection carried out on the equipment / device(s)

Please describe the equipment / device(s) being used:

In your opinion, was the condition of the workplace/working environment a contributory factor to the accident

If yes, please state why;

In your opinion, did the injured person contribute to the accident in any way; if yes, please state why;

In your opinion, did other persons contribute to the accident in any way; if yes, please state why;

Accident Investigation Report

Induction Yes No

Had the injured person received health and safety induction Date of Induction:

Risk Assessment

Had risk assessment been carried out on the work associated with the accident

If yes, what is the risk assessment reference number RA

Had the risk assessment been shown to the injured person Did the injured person sign for receipt of the risk assessment Did the risk assessment identify the hazard

Safe working Procedure/Practice/SOPs

Is there a safe working procedure for the work associated with the accident

If yes, what is the safe working procedure reference number SWP

Had the injured person been shown the safe working procedure Did the injured person follow the safe working procedure

Did the injured person sign for receipt of the safe working procedure

Training

Had the injured person received any training in relation to the job If yes, on what date was the training carried out

Was the training documented

Did the injured person sign for receipt of the training

Important:

1. Review the risk assessment in relation to this accident 2. Make or recommend improvements

3. Review any safe working procedure associated to the task 4. Make amendments accordingly

5. Prohibit the use of the area/equipment if necessary

6. Re-issue any amended post-accident risk assessment immediately 7. Re-issue any amended safe working procedure immediately

8. Re-train if necessary

Ensure that all employees issued with accident risk assessment, post-accident safe working procedure and post-post-accident training sign for receipt.

Accident Investigation Report

Standard Disclosure List – A Copy of the following documents

must be attached to this report - if relevant Please tick

Accident book entry First aider report

Manager/Supervisor accident notes

RIDDOR report to HSE (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations)

Other communication between company and HSE

Minutes of Health and Safety Committee meeting(s) where accident/matter considered

Report to DSS Induction Training

Evidence of equipment maintenance (if applicable) Evidence of pre-operational inspections (if applicable)

Evidence of training given in relation to accident (Safe Working Procedure, Safe Working Practice, Safe Operating Procedure) Pre accident-Risk Assessment

Post accident-Risk Assessment Pre accident-Safe Working Procedure Post accident-Safe Working procedure

PPE issued (Personal Protective Equipment) if applicable Photographs where possible

Question; Do I have to make out an Accident Investigation Report for all accidents? Answer: No, not for negligible injuries such as, scratches, bruises, bumps, grazes.

Nor for minor injuries such as, lacerations not requiring stitches or minor head injuries

Accidents that must be reportable under the RIDDOR Regulations

Reporting of Injuries, Diseases and Dangerous Occurrences Regulations1995 (RIDDOR) Regulation 3 (notifying and reporting) and 7 (recording)

What must you do?

Death or Major Injury:

You must notify the Health and Safety Executive (HSE) or local authority as soon as you can, if someone has died or suffered a major injury as a result of an accident at work. This can be a Clipper Logistics Group employee, a self-employed person working on Clipper Logistics Group premises, someone else at work, or people not at work, e.g. members of the public (if the death or major injury “arose out of or in connection with work” i.e. was work-related).

You must also make a report within 10 days, via the below contacts, or by sending in a report form (F2508) to:-

Fax: 0845 300 9924 (any time)

Accident Investigation Report

Definitions of Reportable major injuries

• Fracture other than to fingers, thumbs or toes. • Amputation.

• Dislocation of the shoulder, hip, knee or spine. • Loss of sight (temporary or permanent).

• Chemical or hot metal burn to the eye or any penetrating injury to the eye. • Injury resulting from an electric shock or electrical burn leading to

unconsciousness; or requiring admittance to hospital for more than 24 hours. • Any other injury; leading to hypothermia, heat-induced illness or

unconsciousness; or requiring admittance to hospital for more than 24 hours. • Unconsciousness caused by asphyxia or exposure to a harmful substance or

biological agent.

• Acute illness requiring medical treatment where there is reason to believe that this resulted from exposure to a biological agent or its toxins or infected material.

• Acute illness requiring medical treatment, or loss of consciousness arising from absorption of any substance by inhalation, ingestion or through the skin. • Any injury to people not at work as a result of an accident “arising out of or in

connection with work” where they are taken to hospital from the scene of the accident.

Over Three Day Injury:

You do not have to notify these to HSE or the local authority as quickly as you can,

but you must report them within ten days.

If there is an accident connected to work (including an act of physical violence) and the employee or self-employed person working on your premises, suffer an over three day injury you must send a completed accident form (F2508) to the enforcing authority within ten days.

Alternatively, you can report to the accident contact centre via a number of methods.

By phone 0845 300 9923 (8.30am-5.00pm) By fax 0845 300 9924 (any time)

By internet www.riddor.gov.uk (any time)

An over three day injury is one which is not necessarily major but results in the injured person being away from work or unable to do the full range of their normal duties for more than three days (including any rest days they wouldn’t normally be expected to work such as weekends, rest days or holidays) not counting the day of

Accident Investigation Report

Reportable dangerous occurrences

If something happens which dose not result in a reportable injury, but which clearly could have done, then it may be a dangerous occurrence which must be reported immediately (e.g. by telephone)

Within ten days you must follow this up with a completed accident report form (F2508)

Reportable dangerous occurrences are;

Collapse, overturning or failure of load-bearing parts of lifts and lifting equipment; Explosion, collapse or bursting of any closed vessel or associated pipe work; Failure of any freight container in any of its load-bearing parts;

Plant or equipment coming into contact with overhead power lines; Electric short circuit or overload causing fire or explosion;

Any unintentional explosion, projection of material beyond a site or boundary, injury caused by an explosion;

Accidental release of a biological agent likely to cause severe human illness;

Failure of industrial radiography or irradiation equipment to de-energise or return to its safe position after the intended exposure period;

Malfunction of breathing apparatus while in use or during testing immediately before use;

Failure or endangering of diving equipment, the trapping of a diver, an explosion near a diver, or an uncontrolled ascent;

Collapse or partial collapse of a scaffolding over five metres high, or erected near water where there could be a risk of drowning after a fall;

Unintended collision of a train with any vehicle;

Dangerous occurrence at a well (other than a water well); Dangerous occurrence at a pipeline;

Failure of any load-bearing fairground equipment, or derailment or unintended collision of cars or trams;

A road tanker carrying a dangerous substance overturns, suffers serious damage, catches fire or the substance is released;

Accident Investigation Report

Unintended collapse of: any building or structure under construction, alteration or demolition where over five tonnes of material falls; a wall or floor in a place of work and/or scaffolding for example.

Explosion or fire causing suspension of normal work for over 24 hours;

Sudden, uncontrolled release in a building of: 100kg or more of flammable liquid; 10kg of flammable liquid above its boiling point;

10 kg or more of flammable gas; or of 500kg of these substances if the release is in the open air;

Accidental release of any substance which may damage health.

Reportable diseases

If a doctor notifies you that an employee suffers from a reportable work-related disease then you must send a completed disease report form (F2508A) to the enforcing authority.

You can simply ring the HSE to check whether a disease is reportable.

Reportable diseases include:

Certain poisonings;

Some skin diseases such as occupational dermatitis, skin cancer, chrome ulcer, oil folliculitis/acne;

Lung diseases including: occupational asthma, farmer’s lung, pneumoconiosis, asbestosis, mesothelioma;

Infections such as: leptospirosis; hepatitis; tuberculosis; anthrax; legionellosis and tetanus;

Other conditions such as: occupational cancer; certain musculoskeletal disorders; decompression illness and hand-arm vibration syndrome.

Is the accident/incident reportable under the RIDDOR regulations Yes No

Is the report a; Major Injury

Dangerous Occurrence Reportable Disease Over three day injury Who made the report; Name

How was it reported (telephone, Fax, internet) Have you received a copy of the report

Accident Investigation Report

You must keep a record of any reportable injury, disease or dangerous occurrence for a minimum of three years after the date of which it happened.

This must include:

• The date and method of reporting • The date, time and place of the event • Personal details of those involved

• A brief description of the nature of events

What should I do with the accident investigation report now that it has been completed?

A copy of the completed accident investigation report and all relevant documents should be kept under lock and key on site.

The original completed accident investigation report and all relevant documents should be sent without delay to:

Carol Heaton

Clipper Logistics Group Gelderd Road

Leeds LS12 6LT

Fax Number; 0113 204 2085

Telephone Number: 0113 204 2050

E-mail address HealthandSafetyAdmin@clippergroup.co.uk Useful Telephone Numbers for Health and Safety Advice;

Leonard Breheney (North) 07775 702 011 Caroline Bate (South) 0208 344 5342